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Run: Prior Authorization Request and Tracking Log

Track each prior authorization request from submission to approval, denial, and renewal in one log. Use it to reduce missed follow-ups, capture visit limits,...

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Request Details

Request Date (required)

Date the prior authorization request was submitted to the payer.

Patient Identifier (required)

Use the internal patient ID or medical record number. Do not enter SSN or other unnecessary PII.

Payer Name (required)

Name of the insurance payer or plan.

Service Requested (required)

Brief description of the procedure, visit, medication, or service requiring authorization.

Request Type (required)

Authorization Status

Current Status (required)

Submission Method

Payer Reference Number

Reference or case number assigned by the payer.

Turnaround Time (Days)

Number of days from submission to payer decision or current status update.

Follow-Up Due Date

Next date to contact the payer if no decision has been received.

Approval and Visit Limits

Authorization Number

Authorization number issued by the payer.

Approval Date

Date the payer approved the request.

Effective Start Date

Start date for the approved authorization period.

Effective End Date

End date for the approved authorization period.

Visit Limit

Maximum number of visits, units, or occurrences authorized.

Limit Unit

Denial and Follow-Up

Denial Reason

Brief payer-provided reason for denial or partial denial.

Appeal Required?

Select if the denial will be appealed.

Yes No N/A

Appeal Due Date

Deadline to submit the appeal, if applicable.

Follow-Up Action

Notes

Operational notes, call outcomes, or documentation reminders.

Submission and Audit Trail

Submitted By (required)

Name or team responsible for the submission.

Last Updated

Timestamp of the most recent status update.

Internal Reference

Optional internal tracking number or case reference.

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